[Deferred prostatectomy after active surveillance-results from a single center]. / Verzögerte Prostatektomie nach Active Surveillance ­ eine prospektive Patientenbeobachtung.

BACKGROUND: Follow-up during Active Surveillance (AS) may result in psychological burden and discomfort due to the constant clinical monitoring. Therefore, successful implementation of AS is to some extent a challenge for the patient and the caregiver. MATERIALS AND METHODS: In this monocentric study, we analyzed the reasons for termination of AS and the rate of the postoperative adverse pathology (AP) in patients who underwent deferred radical prostatectomy (RP) after AS. These results were compared with AS candidates who underwent immediate RP. P-values were calculated with the Χ2 test. RESULTS: After 21 months of follow-up during AS, a deferred RP was performed in 74 patients. On the other hand, 214 patients underwent immediate RP. AP (Gleason score ≥7b, ≥pT3a, R1 and N+) was common in the AS group and this was statistically significant (45% vs. 29%, P-value <0.001). CONCLUSION: These findings reflect many deficits in the current AS protocols. Using the available tools to apply AS in the routine clinical practice setting may be not adequate to afford oncological safety. This requires the development of new diagnostic tools like new imaging techniques and innovative biomarkers that provide the clinician with more accurate data about disease progression and subsequent help to achieve better outcomes in active surveillance candidates.

Robotic Salvage Lymph Node Dissection in Recurrent Prostate Cancer: Lessons Learned from 68 Cases and Implications for Future Clinical Management.

PURPOSE: Salvage lymph node dissection is a rescue treatment for patients with nodal recurrence after radical prostatectomy. Very limited data are available on robotic salvage lymph node dissection. Our purpose was to investigate perioperative and oncological outcomes of robotic salvage lymph node dissection in a large monocentric series. MATERIALS AND METHODS: Perioperative data, complications within 30 days after surgery and oncological outcomes as assessed by histology, prostate specific antigen changes, prostate specific antigen nadir after salvage lymph node dissection, and time to further therapy were analyzed. To identify predictive factors for oncological outcome, Kaplan-Meier and Cox-regression analyses were performed. For cases with a mismatch between preoperative positron emission tomography/computed tomography and the number of histologically positive lymph nodes, prostate specific membrane antigen immunohistochemistry was performed on removed lymph nodes. RESULTS: A total of 68 patients underwent robotic salvage lymph node dissection with a median operation time of 126 minutes, a blood loss of 50 ml, and a length of stay of 4 days. No major complications (>Clavien 3) occurred. Median followup was 12.1 months. Median time to further therapy was 12.4 months, 37% of patients experienced complete biochemical response (prostate specific antigen <0.2 ng/ml) and 11% reached an undetectable prostate specific antigen, which was maintained for >1 year in 3 cases. Lower preoperative prostate specific antigen, longer time between radical prostatectomy and salvage lymph node dissection, preoperative prostate specific membrane antigen positron emission tomography/computed tomography and complete biochemical response after salvage lymph node dissection were significant predictors of longer therapy-free survival (all p <0.005). Prostate specific membrane antigen immunohistochemistry revealed that prostate specific membrane antigen positron emission tomography/computed tomography tends to miss small lymph node metastases <5 mm. CONCLUSIONS: Robotic salvage lymph node dissection is a feasible approach with low perioperative morbidity and delays further systemic therapy in most patients. Prostate specific membrane antigen positron emission tomography/computed tomography detection is mostly limited to tumor foci >5 mm.

[When a urological emergency indicates an internal medical crisis : Priapism as the first clinical manifestation of leukemia]. / Wenn ein urologischer Notfall auf eine internistische Krise hinweist : Priapismus als klinische Erstmanifestation einer Leukämie.

Priapism as a sign of a severe hematological disease is a rare event, which has to be considered as both a urological and a hematological emergency that requires immediate treatment. This article describes a clinical case of priapism as the first clinical manifestation of a hitherto undiagnosed chronic myeloid leukemia (CML) and discusses the results of a literature review on this topic.

Robotic salvage lymph node dissection for nodal-only recurrences after radical prostatectomy: Perioperative and early oncological outcomes.

BACKGROUND: Salvage lymph node dissection (sLND) - performed open or minimally-invasive - is a treatment modality that can be offered to patients with nodal recurrence after radical prostatectomy (RP), especially in times where modern imaging methods like choline- or PSMA-PET/CT are available. Yet, there are only very limited data on the safety and oncological effectiveness of robotic sLND. METHODS: We retrospectively identified patients who underwent robotic sLND at our institution between 2013 and 2017 for nodal recurrence after RP, which had been diagnosed either by 18F-choline- or 68Ga-PSMA-PET/CT. We analyzed perioperative data and early oncological outcomes with a focus on the comparison of patients with preoperative choline- vs. those with preoperative PSMA-PET/CT. RESULTS: We identified 36 patients who underwent robotic sLND at a median time of 45.3 months [range 3.1;228.6] after RP, with nodal recurrences detected in 25 patients by PSMA- and in 11 by choline-PET/CT. Median preoperative PSA, operation time and blood loss were 1.98 ng/ml [range 0.09;35.15], 129.5 min [range 65;202] and 50 ml [range 0;400], respectively. No high-grade complications occurred. A median number of 6.5 [range 1;25] lymph nodes were removed with a median of 1 [range 0;9] tumor-occupied node. None of the patients received any adjuvant treatment. Median postoperative PSA-change was -57% [range -100; +58] in the PSMA- and +10% [range -91; +95] in the choline-group (p = 0.015). 44% of patients in the PSMA- and 18% of patients in the choline-group experienced complete biochemical response (cBCR; PSA <0.2 ng/ml). Median time from sLND to the initiation of further therapy was 12 months [range 2;21.5] in the PSMA-group and 4.7 months [range 2.2;18.9] in the choline-group (p = 0.001). CONCLUSIONS: This is the hitherto largest series on robotic sLND for nodal recurrence after RP. Robotic sLND is a feasible therapeutic option with low morbidity, which can at least delay the initiation of further therapy - in some patients up to several years. However, the extend of sLND has to be standardized and randomized trials are needed to finally define the oncological effectiveness of this approach.